patient patience

Sometimes I catch myself unreasonably annoyed or frustrated with a patient.  At the end of three 12 hour shifts, it often doesn’t take much on the side of the patient to make my inner eyebrow rise up in annoyed incredulity.  Mmhmm I say, so it seems that you have had a fever and have ben vomiting since an onset of 1 hour ago.  I see.  Welcome.  Welcome.  

See what I mean about the unnecessary snark? Check yo’self. 

I try hard with every single patient to guard against my own judgments and knee jerk instinctions towards them or their situations, whether those are negative or positive.  I do my best to approach each new situation with an unbiased clean slate, to listen with my full attention to discern what is actually going on, and to put aside myself to focus on the situation at hand.  I know that interjecting my own bias just colors my thinking in a way that is not productive.   I know enough to know that I am not yet smart enough to rise mentally above the frustrations and see a situation for what it actually is, be that a sick “well-patient” or a surgical abdomen, especially if the patient is yelling in my face or insulting me throughout the encounter.  It’s hard sometimes to know what skills will come with time, and what skills I want to make sure to keep at bay with time.  Delicate balances.  

There are days that I seem to be swimming in a sea of mundane repetition, and days where I feel so incredibly unprepared for the real world.  I work with colleagues who have patience with me and demonstrate proper techniques, ask me questions constantly and push me to think as an independent provider.  And I work with others who start the day by telling me how much they hate working with students, how I will make their shift seem cumbersome and unwieldy.  It’s this weird winding path that can change with each shift.  I sometimes get pushed to the side, or cut off, or ignored entirely, and other times I am functioning as part of the team, writing scripts, putting in orders, being heard.  I try to remember that each separate experience is combining together to create a whole picture, and that picture is what I am bringing forward with me.  In addition to the medicine, I am learning about work relationships, and collaboration, cooperation, communication.  All those poster board buzz words.  Metaphorical trust falls and all that jazz.  

In general though, especially when I am feeling stretched my most thin, I invariably have a patient who pulls the ground back under my feet.  Last week that patient was a man with Parkinson’s who was in the ER for an evaluation of his pinky finger after a recent fall.  He was my last patient of my last shift.  Ability to express compassion was waning.  

Sitting lopsided on his hospital stretcher with his cane propped across his lap and held loosely by tremulous hands, suspenders pulled taut across his angled shoulders, he slowly raised his head to greet me as I bustled into the room.  As with most times in the ER, outside his glass door I could hear IV pumps going off with intermittent high pitches beeps, the intercom blaring in reports from the incoming ambulance crew, people laughing at the nurses station, and the mammoth xray machine lumbering noisily down the hallway.  It’s easy to let distraction sink in.   I forced myself to bring my attention forward as I pulled my chair bedside.   

He was a slow talker, preferring to take his time to correctly answer my questions after proper thought.  His body lists to the right now, often precariously, and falling often is nothing new for him.  He used to be a high school math teacher.  Now he writes poetry.  He fell on his right pinky this morning, and now it’s stuck in an abnormal position.  It doesn’t really hurt too much, but he can’t move it, and that’s cramping his style.  His teenage son dropped him off and his wife will come to pick him up when he is done.  

His xrays showed a dislocation, but luckily no acute fracture.  I was happy because I’ve never reduced a dislocation, and fractures are consulted out to orthopedics.  Plus, I could use the practice performing nerve blocks.  

I’m working with a doc who does things Just. So.  His precise preferred methodology is often just a hair off from how my novice hands clumsily perform them, and I know that it drives him crazy.  He blocked the lateral portion of the finger and I the medial.  Below the finger we injected were a pile of the patient’s poems.  He likes to carry them with him.  He’s self-published and working on book number two.  While we waited for the anesthetic to kick in, he handed us each one poem to read.  We read them at the doctors station.  I don’t like poetry, and I was a little nervous that I would do more harm than good when I yank that finger forward an back into it’s fitting place.

I applied traction and pressure and the joint popped back into place with a palpable and audible snap.  My doc says you did good, but doing it this way would have been better.  

As I slowly taped his fingers together, we discovered that we are both from Minnesota.  It’s always an unexpectedly nice surprise when I meet people from my home.  A little piece of Minnesota nice is never a bad thing to encounter at the end of a busy day. 

He gave me two of his poems to bring home after my long shift.  One to make me laugh and one that’s more somber.  I told him we would forever share a bond because his finger was my first dislocation reduction.  He laughed and said I handled it like a pro, he would never have guessed.  

I stepped out of his room and back into the chaotic hallway, and I realized that I felt better again. Grounded.  

snowy sunday stroll

One of my favorite parts of living in an area that has all four season, is the beautiful, calming tranquility of fresh snow falls.  There is just nothing like it, new snow makes the world seem like a whole new place.  This winter has been a bit lacking in that department for me.  We had one little baby snow fall before I left for Belize, and since I've been back we haven't had much either.  Or I suppose we have had a few scattered storms, but they happened to occur during times that I was driving long distances, and thus I did not get to experience any of the calm, the beauty, or the tranquility.  Luckily for me, this past Sunday we had the perfect snow fall.  Big flat chunky blobs of snow fell all morning, piling up into fluffy dunes, and blanketing the park in covered silence. 

Our little family is a mixed bag of emotions when it comes to snow.  JP, armed with long underwear, smartwool socks, neck buff, scarf, heavy gloves, and brand new Bean boots, has really come over to the side of enjoying snow falls.  I like to think he has similar feelings to the ones I expressed above, but I know he still pines for sunny californean days as well.

Oliver LOVES snow.  He acts like snow is a special treat falling from the sky specifically for him.  He gets super giddy and riled up, and when we let him off leash, he runs full steam ahead with his mouth open and low so he can ingest as much fluff as possible.  He frolicks and scampers and has a constant poof of whiteness covering some portion of his face and head at all times. You can see him blasting in at a running sideways slant to photo bomb my picture below:

And little Yinny is the odd one out.  She hates/barely tolerates/glares her way through all that is involved in winter. If you are looking at her during a walk, she will quickly switch from a normal walk to hobbling on only three legs at a time, while making her eyes as big and round as possible, and softly whimpering.  If you don't look at her, she slowly shuffles along behind the group with her head hung low, looking wilted and dejected.  She loves walking with JP because he inevitably takes pity on her and scoops her up and away from all the evil snow.  I, on the other hand, heartlessly make her exercise.  

All three personalities summed up in one photo:

clinics: mobile, stationary, and home bound

I started back to real life almost three weeks ago.  Well, I suppose it's more like the third layer of real life as it relates to the most recent holidays.  Layer 1: back in the US, layer 2: back home in Portland after my family left, layer 3: recommence school.  In any case, all that is to say that I am back trying to get into the swing of things in a new hospital with new faces, new room layouts, new nurses, new EMR, new bathrooms to find, new all of the things.  Prior to my first shift, I was talking with Julia on the phone on our shared far apart commute as is our customary first day tradition.  We pump each other up so that we feel less silly about what ridiculous things will come out of our mouths probably as soon as we arrive, and then afterwards we debrief about those exact things and laugh about them. But, we realized that we only have two more first days left! Yikes! and Yay? and also Oh Crap!? Hmmm.   

So, before I get sucked further into rotation 6, I knew I needed to unpack Belize a little more.  If these past two years have been any indication, I've gotten a little too good at letting time get away from me on here.  So, without further ado: clinics, mobile, stationary and home bound!

So, the Hillside clinic is located about 8 miles outside Punta Gorda in the Toledo District of Belize in a place called Eldridgeville.  The clinic itself is located on a fenced compound of sorts, and on that compound are various living places for the students and preceptors, as well as education buildings where physical therapy is performed and lectures are listened to.  The students all bunk in Abby's House, which is about fifteen steps from the clinic.

On days when your group works at Hillside, you go on a market run.  Our group did meal planning together and sent money and a shopping list along with those that were marketing.  First stop was the open air market, which was beautiful, chaotic, and fun.  We bargained like the best of them, well at least Natalie did, and we tried to follow her lead.  There was a small fish market there as well, and we braved that once.  I think our definitions of having a fish cleaned and ready were a little lost in translation.  But they sure were tasty!  Following that we would stop at a grocery store to pick up the staples.  Shopping for meals that involve 13 people is anxiety producing to say the least, but I think we all did pretty well!

Working at the Hillside clinic had the advantage of access to more.  More variety of drugs, more testing capabilities on site, more abilities to draw blood and store it properly, more clinical support staff.  It was basically a stand alone, as much as anything else would be in the world of belizean health care.  There were three very basic examination rooms, one had a door and the other two had curtains.  If the place was really hopping, you could see patients out back at the picnic table too. 

On mobile clinics, all bets were off.  We practiced at places ranging from a large cement slab covered with a thatched roof, to operational clinics with all separate examining rooms, to a one room school house that had one single rickety bed that we all rotated using if the patient required a more extensive abdominal exam, to a building so crammed with objects that I had patients sit in a wheelchair while I conducted the encounter.  It was really fun!  It made my brain stretch so far outside the confines of how I viewed traditional medical encounters.  The amount of labs I ordered in the entire time I was in Belize could be counted on my two hands.  We were pushed to hone our clinical skills to a fine point, to depend more on what we could illicit and feel and see rather than hiding behind scathes of unnecessary tests that so often buffer patient visit in the US, because often we couldn't even order them and if you did order them, it would take months to get results back.

  

 

It felt like MEDICINE and less like covering yourself for fear of impending litigation.  And it was frustrating, and hard and difficult for the same reasons that it was eye opening and exhilarating.  It's scary to prescribe medicines based on lab work that wasn't done the day before, or to know how much time will pass before the mobile clinic comes back to more rural villages.  It's hard to know what exactly the patient is telling you when you are working through a translator, and it's scary to think about how much better they could be managed in a different situation.  Which isn't always true, of course, but there were more than a few cases that kept me up at night with the frustrations of comparisons coming from a country so wealthy and so full of ways to squander that wealth.

We spent one night camped in a school room in the village of Aguacate after a failed attempt to make it to a village further away.  Thwarted by recent rainfall and a low road.

There were most definitely rats squeaking in our ears all night, scorpions hidden in the corners, and a giant spider lurking in what I shall loosely term a commode.  Luckily for me, I hadn't really slept the night before, so after Natalie and I strung up our bed feet to feet style on top of two narrow desks, and covered our entireties with mosquito nets.  I popped ear plugs in to ward away any interested passing insect parties, and actually slept fairly well all things considered!

The next morning while we were drinking coffee and eating our breakfast before opening the clinic, a woman walked upp to us and told us she was in labor and needed to go to a hospital.  She was extremely calm, and we talked to her for a good ten minutes trying to overcome the language barrier and ascertain that we were all talking about the same things.   Our preceptor took her down to the clinic and did an exam, which determined that she was in fact 6 cm dilated.  They made a makeshift bed in the back of the van and headed off to the nearest hospital, leaving just us poor students to hold down the clinic.  Here we are nervously putting our hands on deck as the van pulls away in the back ground!

Surprisingly, we didn't kill anyone!  We consulted with each other on medication adjustments, differentials, and treatment plans.  All things considered it went quite smoothly, but it was a pretty terrifying two hours of solo practice!

Home visits are something that has really fallen out of medicine in the US.  In Belize, we had a small number of patients who were home bound, and thus required us to come to them.  It was such an interesting and broadening experience to gain a glimpse of the day to day life that these people lead.  We examined patients who were laying in hammocks, navigated a yard guarded by a menacing turkey, hoofed up a muddy hillside post excessive rainfall, and crammed a group of seven into a room the size of a closet.  Home health care in Belize is fun!

We all pitched in together to make the best of every situation we encountered.  We worked as a group to push through the things that made us uncomfortable, to learn more about the conditions we lacked knowledge in, and collaborated to make the most out of this international medical experience.   I know I am so fortunate, and so blessed to have been a part of this experience, and to have shared a small part in the organization as a whole.  I will graduate in May, look out international medical organizations, I am coming for you!

stitch it, stitch it good

Ok, seriously I spent an inordinate amount of time trying to upload pictures to my next blog post, which actually shows more of what we were doing medically while in Belize.  But this *&%#$ host site sometimes drive me up a wall with it's frustratingly annoying quirks that include (but most certainly are not limited to) choosing to upload only certain photos and not others for no particular reason, freezing on the photo load page, and in general being a wonky pile.  Never fear folks, my computer programmer fiance is swooping to my rescue and together we are designing a new updated webpage that will hopefully solve all my first world problems. IN ANY CASE, while that is in the works, and while blogger slowly figures out just what exactly I want it to do in my next post, I have a story for you.

So, ED yesterday, day two, still settling in.  Finding my grounding, cracking very innocent, tentative medical jokes with my new preceptors to ease the awkwardness, and sucking up like mad to all the nurses and techs.  Towards the end of my shift I picked up a chart for a patient needing a stool disimpaction.  This is like par for the course in the ED, but somehow I have managed to miss all those cases thus far, so I signed myself up.  Confidence is key, Walsh! Anyway, as I ever so confidently strode towards that room I passed the trauma bay.  Literally did a moonwalk style double take so I could adequately take in the gaping leg laceration on the table.  And yes, I do know that people probably hate it when they are referred to as the body part in which they have come to the department in complaint of, but get there.  And by there, I mean get to me with my double take.  Seriously, when he flexed his leg there was muscle bulging out.  I stared for a cool three seconds, didn't want to appear too weird guys, and in my head I said. YUP, I'm gonna sew that.  I'm gonna sew the hell out of that.

So, meanwhile I had the disimpaction patient, and I have a seriously funny story that I would love to tell you about that, but, it's the kind of story that cries out for real time facial expressions and wild hand motions, and I am just not sure I have the literary prowess to capture it adequately in word form.  But if you see me in real life, please ask me to elaborate and I will indeed.  Add it to my top three ridiculous medical stories.

Back to the leg lac.  Of course I am standing in the middle of the swamped ED, plotting how to snag the case.  Picture the real life adult version of the anxious toddler potty dance, and I was doing a metaphorical one of those.  I still have some hesitancy in grabbing charts out of order, which is actually a totally encouraged thing to do when you are a student, but the OCD in me feels weird cutting in line like that.  So I just potty dance hovered until room 2A was next in line, and then real casual like grabbed the clipboard and flipped to the intake form.

Case thus snagged, I tromped myself into the trauma bay to introduce myself and assess the situation.  I know it's the past CNA in me that makes me stop before undressing wounds or deciding a patient's NPO status, or making a variety of decisions, because I always hesitate and think I need to get an adult, but then I remember that I am actually the person that I would have gone to get, so I force myself to at least appear comfortable doing those things and making those decisions.  In any case, I did the things, assessed the wounds, ordered the xrays, and presented to the attending.

He of course asked me if I had sutured before.  To which I promptly and gamely replied oh yes.  And while technically that's not a lie, it is also technically true that I have thrown more stitches on dead animals than I have on live humans.  But still, I have done it before.  Six stitches on three seperate occasions say yes, so yes, of course I've done this before.  Old hat and all that.

Side note here, it's remarkable how much I feel like being in the ED is 'fake it tell you make it' as a student.  My classmates tell me the same things.  Have I done injections, well, does a troll doll count? Cause if yes, then yes.  It's exhilarating and terrifying, and awesome, but bizarre. 

So, we anesthetized the wound, which in itself was something I hadn't yet done in real life.  It was awesome.  Needle, meet jagged wound edges.  Repeat.  Yet another time in my life that I actively thought, thank god this doesn't make me want to pass out, because, cool.  

And then I safety pinned my engagement ring onto my shirt and asked for a size 6 sterile glove and got to work.  And I sutured the crap out of that lac.  24 stitches later I had literally quadrupled my previous human number!  While I tucked that muscle back into his calf we talked about his three grand kids, and the crazy cold weather we've been having, and how dry it is all the time in Denver, and what it's like in MN in the winter, and how incredibly nice small town parades are.  The whole time I tried to channel the spirit of my amazing seamstress of a grandmother, and I think I did her proud. 

When I left that shift all I could think was, holy crap it's awesome that I get to do this for a living.  And then I took this picture, and blogger miraculously uploaded it. Case closed.